HomeMy WebLinkAbout0749 MAIN STREET (OST.) - Health 49;Main Street
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Commonwealth of Massachusetts
p Title 5 Official Inspection Form :
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
1WV749 Main Street h:e
Property Address
First Property Mgmt,
Owner Owner's Name Jz
Information is `a
required for every Osterville MA 02655 11-6-18 try
page, Cityfrown State Zip Code Date of Inspection },
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the and of the form.
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163 Commercial Street F 5 fNSP
,Q Company Address
Mashpee MA 02649
Cl n State Zip Code
508-408-477-8877 S1623
Telephone Number License Number
B. Certification'
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
lapectol's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority,
Please note: This report only describes conditions at the time of Inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future underthe same or different conditions of use.
t5insp.tloc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Paget o1 to
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
information is
required for every Osterville MA 02655 11-6-18
page. CityJTown State Zip Code
Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3,or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system is all 500 Gal. Tank 0 Box and Two pits
2) System Conditionally Passes;
❑ One or more system components as described In the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes","no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltralion or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certfcate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
N
15insp.doc•rev.712 612 0 1 8 Title 5 official Inspection Form!Subsurface Sewage Disposal System-page 2 o1 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Stre
et
Property Address
First Property Mgmt,
Owner Owner's Name
information is required for every OSterVllle MA 02655 11-6-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.3030)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-6-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well,
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
15insp.doc•rev.71261201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
information is required for every Osterville MA 02655 11-6-18
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary,(cont.)
4) System Failure Criteria Applicable.to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
D ® Liquid depth in asmajowt Is less than 6"below invert or available volume is less
than%day flow PIT
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
11 ® The system falls, I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,1)00 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
f
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Offidal lnspecdon Form:Subsurface Sewage Disposal System-Page 5 of is
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt
Cwvner Owners Name
information,is required for every
pSterville MA 02655 11-6-18
page. Cltyrrown State Zip Code Date of Inspection
C. Inspection Summary (cost.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants.if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5))
t5insp.doc•rev.71281201a Title 5 official Inspection Fonn:Subsurface Sevwage Disposal System•page 6 of 18
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y
749 Main Street
Ll Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-6-18
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
1500 Gal. precast Tank D Box and two pit's.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Does residence have a water treatment unit? ❑ Yes ❑ No
If yes,discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
t5lnsp.doc-rev.T12612018 Title 5 Ofidal Inspection Form:Subsurface sewage Disposal system-page 7 of 1a
L abed xed dH £I,U 8 60Z b 1• AON
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-6-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2, Commerciallindustrial Flow Conditions:
Type of Establishment: Office
Design flow(based on 310 CMR 15.203): 660
Gallons per day(gpd)
Basis of design now(seatslpersons/sq.ft., etc.):
75 gpd/1000sft
Grease trap present? ❑ Yes ® No
Water treatment unit present? ❑ Yes ® No
If yes, discharges to
Industrial waste holding tank present?' ❑ Yes No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available: NA
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Yearly Pumping
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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9 a5ed xed dH b I,U 8 i3OZ b I• ^oN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
Information is required for every Osterville MA 02655 11-6-18
per, Cityffawn State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box,soil absorption system
❑ Single cesspool
❑ overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1984 Permit # 83 -843,
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 561,
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage,etc.):
Pipeing is 4" PVC SCH 40.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V
749 Main Street
v
Property Address
First Property Mgmt.
Owner Owners Name
information is required for every Osterville MA 02655 11-6-18
page. City/Town State Zip Code Date of Inspectlon
D. System Information (cost.)
6. Septic Tank(locate on site plan):
Depth below grade: 40"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gallon H-20
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined? Asbuift-Tape Past Report
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank at working level wlboth covers steel at grade. Inlet tee.Outlet baffle,Tank at 40" below
grade, No sign of over loading or leakage.
M
I
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Commonwealth of Massachusetts
U�,_v
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
requir on is Osterville MA 02655 11-6-18
requiredd for every
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle conditlon, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
B. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
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Commonwealth of Massachusetts
UTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
information is
required for every Osterville MA 02655 11-6-18
page. City/Town Stale Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box not opened under black top camera out to box. No sign of over loading or solid carry over.
Box look's to be solid and clean.
iI
4
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments .
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information required
is every Osterville
squired for MA 02655 11-6-1 B
page. City/Town State Zip Code Date of Inspedlon
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No`
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
£l, abed xed dH 5l•:£Z 8l,0Z t7l, AoN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
W749 Main Street
Property Address
First Property Mgmt.
owner Owner's Name
information is required for every Osterville MA 02655 11-6-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two precast pits wlsteel cover's at grade. Pit 2 30"water. Pit 1 water level @ 12"
below inlet.
12. Cesspools (cesspool must be pumped as part of inspection) (locale on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 P Y ry
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
Information Is
required for every Osterville MA 02655 11-6-18
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
11 Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
l5inap.doc•rev.7!282018
Title 5 Offidsl Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
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Commonwealth of Massachusetts
> Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information is
squired for every Osteryille MA 02655 11-6-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® dirawing attached separately
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for voluntary Asses$Menls
749 Main Street
- - ,—_Property Address
First Property Mgmt.
Owner Owner's Name __......
mrarosalion is -
requirec(or every Oslervill2 _ _ MA 02655 _pale. CiIY/rorr &ace Zip Code Date o1 insp_ec't an
D, System Information (cons.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to
at'east:wo permanent reference,andmarks or berchmarks. Locate ell wens within 100 feet. Locate
where putAlc water supply enters the building. Check one of the boxes below.
❑ hand-sketch in the area below
® drawing attached separately
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-6-18
per. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
IV
Estimated depth t high ground water: 1
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked,date of design plan reviewed: 9-22-83
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Area and site high. No G.W. problem T.H. on design plan 9/22/83 no G.W.at 12'.
IVII Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5nsp.doc tev.7126/2016 Title 5Official Inspection Form;Subsurface Sewage Disposal System•Page 17 at 1e
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
749 Main Street
Properly Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-6-18
pap. Citylrom State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3,or 5 completed as appropriate
N
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
9
N� Gw
t5lnsp.doc•rev.W281201 B Title 5 OlPldal Inspectlon Form!Subsurface Sewage Disposal System•Page 18 of 18
61, a5ed xed dH L 6:£Z 8 60Z b 6 ^oN
t Nov 11 2015 23:16 Jim The Inspector Man 5085349919 page 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Mai r
• n Street
Property Address
First Property Mgmt. r q
Owner Owners Name
information is
required for every Osterville MA 02655 11-9-15
page: Cityfrown State Zip Code Date or Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information filling out forms \ �t►uuunu ,
on the computer, jH OF hfA r 11z,,,
use only the tab 1. Inspector:
key to move your
cursor-do not
James DSears ?�� JA.MES ;m
use the return . =
Y• _
ke Name of Inspector s c� ;co
�*
Capewide Enterprises, LLC
J Company Name.
153 Commercial Street i�rF/Sn N SPEG���`'�
Company Address
Mashpee . MA 02649
Cityrrown Stale Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 6(310 CMR 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11-9-15
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
„"This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins 3113
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
r
Nov 11 2015 23:16 Jim The Inspector Man 5085349919 page 20
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information is
required for every OStefYllle MA 02655 11-9-15
page. CityrTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E!always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1500 Gal Tank D Box and two pits
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon.completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old`or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 2 of 17
Nov 11 2015 23:16 Jim The Inspector Man 5085349919- page 21
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'f 749 Main Street
Property Address
First Property Mgmt.
Owner owners Name
information is
required for every Osterville MA 02655 11-9-15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below).
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
.the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines.in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
f5ins-3113 Title 5 Official Inspe-Aion Forth:Subsurface Sewage Disposal System•Page 3 of 17
Nov 11 .2015 23:17 Jim The Inspector Man 5085349919 page 22
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property M mt.
Owner Owner's Name
information is
required for every Osterville MA 02655 11-9-15
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the.public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply. .
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a'private water
supply I well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
i
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No .
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6" below invert or available volume is less
than %day flow
15ina•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Nov 1,1 2015 23:17 Jim The Inspector Man 5085349919 page 23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information is
required for every Osteryille MA 02655 11-9-15
page. Clty[Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well
❑ . ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.)
® The system is a cesspool serving a facility with a design,flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Nov 11 2015 23:17 Jim The Inspector Man 5085349919 page 24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt
Owner Owner's Name
information Is psterville
required for every MA 02655 11-9-16
page. Cltyrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)) -
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins•3113 Tille;official Inopedion Form,Subsurface Sewage oleposal Sya`am•Page 6 of 17
Nov 11 2015 23:17 Jim The Inspector Man 5085349919 page 25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth- Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
information is
required for every Ostervllle MA 02655 11-9-15
page. City/Town Stale Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal, precast tank D Box and two pits
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?
❑ Yes ❑ No
Water meter readings, if available(last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy; Date
Commercial/Industrial Flow Conditions:
Type of Establishment: Office
Design flow(based on 310 CMR 15.203); 660
Gallons per day(gpd)
Basis of design flow(seatslpersonslsq.ft., etc.): 75 gpd/1000sft
Grease trap present? ❑ Yes _No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available: NA
(Sins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 7 of 17
Nov 11 2015 23:18 Jim The Inspector Man 5085349919 page 26
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
P a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
Information
ton is
required for every Osterville MA 02655 11-9-1'5
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
I
General Information
Pumping Records:
Source of information: Yearly Pumping
Was system pumped as part of the inspection? ❑, Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
Other(describe):
Minis-3113 T1tle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Nov 11 2015 23:18 Jim The Inspector Man 5085349919 page 27
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
information is Ostervllle
required for every MA 02655 11-9-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1984 Permit#83 - 843
Were sewage odors detected when arriving at the.site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 56"
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40.
Septic Tank (locate on site plan):
40"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
If tank is metal, list age: "
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 Gallon H-10
1 ,
Sludge depth:
t5ins•3/13 - Tille 5 Official Inspection Form:SubsLuface Sewage Disposal System•Page 9 of 17
Nov 11 2015 23:18 Jim The Inspector Man 5085349919 page 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
information is required for every Osterville MA 02655 11-9-15
page. Cilyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
1"
,
Distance from top of scum to top of outlet tee or baffle 1211
Distance from bottom of scum to bottom of outlet tee or baffle
17" •
How were dimensions determined? Asbuilt-Tape Past Report
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level wlboth covers steel at grade. Inlet tee, outlet baffle,tank at 40" below
grade. No sign of over loading or leakage.
g g
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
l5ins-3/13 Tills,5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Nov 11 2015 23:18 Jim The Inspector Man 5085349919 page 29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessmehts
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
information is
required for every Osterville MA 02655 11-9-15
page. Cityrrown State Zlp Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete '❑ metal ❑ fiberglass ❑ polyethylene ' ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•page 11 of 17
Nov 1,1 2015 23:18 Jim The Inspector Man 5085349919 page 30
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property M mt.
Owner Owner's Name
information is
required for every Osterville MA 02655 11-9-15
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cant.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box not opened, under black top camera out to box. No sign of over loading or solid carry over.
Box look's to be solid and clean.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5lns-3113 Titre 5 Official Inspection Form.Subsurface Sewage disposal System Page 12 of 17
Nov 11 2015 23:18 Jim The Inspector Man 5085349919 page 31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
informalion is
required for every Osterville MA 02655 11-9-15
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Typeiname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is two precast pits wlsteel cover's at grade Pit 2 18"water. Pit 1 Full
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
15ins-3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 a117
Nov 11 2015 .23:18 Jim The Inspector Man 5085349919 page 32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0 749 Main Street
Property Address
First Property Mgmt.
Owner Owners Name
Information is
required for evety Osterville MA 02655 11-9-15
page. Citylrown State Zip Code Date of Inspection -
D. System Information (cont.) }
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding,.condition of vegetation,
etc.).-
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 14 of 17
a '
Nov 11 2015 23:19 Jim The Inspector Man 5085349919 page 33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main Street
Property Address
First Property M mt.
Owner Owner's Name
information is
required for every Osterville MA 02665 11-9-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t
r � fA g
/}-a- o
Q 4
C =3 =g7
0
3
O
t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal SWerr Page Y5 of 17
Nov 11 2015 23:19 Jim The Inspector Man 5085349919 page 34
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02655 11-9-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N Estimated depth t 12,+high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 9/22/83
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Area and site high. No G.W.problem t.h. on design plan 9122/83 no G.W. at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3112 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 16 of 17
Nov 1 2015 23:19 Jim The Inspector Man 5085349919 page 35
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main Street
Property Address
First Property Mgmt.
Owner Owner's Name
information is required for every Osteryille MA 02655 11-9-15 .page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, 8, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
,
15ins-3113 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St. D/�i/
Property Address
First Property Mgmt.
Owner Owner's Name
intormatlon is osterville MA 02855 11-13-12
required for every
page. CityrTown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the and of the form_
Important:When . General Information
filling out forms. A ^� ````��gNnnrlr►rrp��r
on the mputer, I .``�� 1�..F....
use onlythe tab 1. Inspector P
key to move your p.• •.y
• G
cursor-do not ,lames D. Sears _ ; JAMES
use
ke the return Name of Inspect
y
_Capewide Enterprises, LLC
Company Name. � !tr - ��
153 Commercial St. _ '''ly1to uINS?
`
Company Address
Mashpee MA 02649
Cityrrown State Tap Code
508-477-8877 S 1623
Telephone Number Ucense Number
B. Certification
1 certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title S(310 CM 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
11-13-12
nspector's,Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future.under
the same or different conditions of use.
t5ins-11110 Title s ' b�sp.U.Form;Sut 30ace Serrage D'RPOW Spt@m•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St.
Property Address
First Property Mgmt_
Owner Owner's Name
information is required for every Osterville MA 02855 11-13-12
page. City/Town state Zip Code Date of Inspecxion
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E I always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•11r10 Title 5 M560 Inspection Form:Subsxfacs Sewsp Disposal System•Page 2 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St
Property Address
First Property Mg
Owner Owner's Name
information is required for every Osterville MA 02855 11-13-12
page. City/Town state Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes (cone):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
I. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
�] Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins 11A0 Tilde 5 McIal rnspection Form:Substaface sewage Disposal System•Page 3 of 17
J
C
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main St
Property Address
First Property Mgmt
Owner Owner's Name
information is required for every Osterville MA 02855 11-13-12
page. city/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system Is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
'*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered_ A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable hcabIa to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
® Liquid depth in Gosepeol is less than 6"below invert or available volume is less
than'/dayflow Pirsp
t5ins•11J10 Title 5 Ohloal Inspection Form Subsurface Sewage Disposal System-Page 4 417
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St.
Property Address
First Property Mgmt
Owner Owner's Name
information is Osterville MA 02855 11-13-12
required for every Citylrovm state Zip Code Date of Inspection
B. Certification (cont.)
Yes No
® Required pumping more than 4 times in the last year NOT due to dogged or
obstructed pipe(s).Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
h no acceptable water quality analysis. his
from a private water supply well with p q ty y [T
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form]
Cl ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure_
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd•
For large systems, you must indicateeither"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is-within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone I I of a public water supply weE
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMRI 15.304.The system owner should contact the appropriate
regional office of the Department
ulna,,tf,0 Me 5 OffilcW twpaction Formi Subswface sewage Disposal System-page 5 of 17
fiN Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main St.
Property Address
First Property Mgmt.
Owner Owner's Name
information is required forevery Osterville MA 02855 11-13-12
page. Ci Irown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes'or"no"as to each of the following:
Yes No
❑ Pumping information was provided by the owner, occupant, or Board of Health
Q ® Were any of the system components pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the
pact baffles or tees, material of construction
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms),
r5ns• 1no TI11e 5 oficial inspection Form:Subsurface Sewage Dispose!System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St
Property Address
First Property Mgmt
Owner owner's Name
informationis required for every Osterviile MA 02855 11-13-12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1500 Gal precast tank D Box and two pits
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ❑ No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
c
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commerciallindusttrial Flow Conditions:
Office
Type of Establishment:
Design flow(based on 310 CMR 15.203): 660
Gallons per day(gpd)
Basis of design flow(seatstpersons/sq.fL,etc.): 75gpd/1000sft
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes 2 No
Water meter readings, if available: NA
t5111s•11110 Ue 5 Offidal Inspection Form Subsurface Sewage.Disposal System•Page 7 ar 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
It Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St.
Property Address
First Property Mgmt
Owner Owners Name
information is
required for every Osterville MA '02855 11-13-12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 09/10/11
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: --
gallons i
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the UA system by system operator under contract
❑ Tight tank Attach a copy of the DEP approval.
❑ Other(describe):
115ins-1 M0 Title 5 Official InWedion Form:Subsurface Sewage Disposal System-Page 8 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St
Property Address
First Property Mgmt.
Owner Owners Name
informationis
required for every Osterville MA 02855 11-13-12
page. Cltyrrown State Zap Code Date of Inspedion
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
1984 Permit # 83 - 843
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
"
Depth below grade: feet
56 6
Material of construction:
❑cast iron ®40 PVC ❑ other(explain): --
Distance from private water supply well or suction line: 10+feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40
Septic Tank(locate on site plan):
Depth below grade: 40"feet
Material of oonstruction:
® concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age: ---
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 Gallon
Sludge depth:
2"
tine•11110 TWO 6 Official Inspection fo":Subwrfaoo Sowoge Diaposaf Syctem-Page 9 eP 17
. 7
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments
749 Main St
Property Address
First Property Mgmt.
Owner Owners Name
information is required for every Osterville MA 02855 11-13-12
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle 12"
Distance from bottom of scum to bottom of outlet tee or baffle 17°
How were dimensions determined? Asbuift-Tape Past Report
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,.structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank at working level wl both covers steel at grade, inlet tee, outlet baffle,tank at 40"below
grade, No sign of over loading or leakage
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions: -
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Dated last pumping: Date
t5ins-1111 D Title 5 ofllcal Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
749 Main St
Property Address
First Property Mgmt.
Owner Owners Name
information is Osterville MA 02855 11-13-12
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Capacity: —
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level.' Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
'Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
tslns•11110 -Title 5 ollrGal lnsoection Form:Subsurface Sewage Disposal System•Pepe 11 cf 17
Commonwealth of Massachusetts
v: Title 5 Official Inspection Form
4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St
Property Address
First Property Mgmt
Owner Owner's Name
infomi for every aUon is
required Osterville MA 02a55 11-13-12
page. CityrFawn State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert No
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box not opened, under black top camera out to box, no sign of over loading or solid carry over
Box look's to be solid and clean
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order. ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
dins-11110 Title 5 Official inspsaion Form:Subswlew Sewage Disposal System•Page-.2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St. .
Property Address
First Property Mgmt,
Owner Owner's Name
requir on is Osterville MA 02855 11-13-12
requiredd for every
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number. 2
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches, number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number
❑ innovative/alternative system
Typeiname of technology: -
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation,etc.):
Leachhing is two precast pits w 1 steel cover's at grade, 18"water in pits, Stain line at 2"', No sign
of over loading or solid can ry over
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert --
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11110 Title 5 Official Inspection Fom[Subsurface Sewage Disposal System-Pape 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 749 Main St.
Property Address
First Property Mgmt.
Owner Owner's Name
information is Osterville MA 02655 11-13-12
required for every _
page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11f10 Tide 5 Official fnspecrion Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St.
PropertyAddress
First Property Mgmt.
Owner Owner's Name
information is required for every Osterville MA 02855 11-13-12
-_
page. Chyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
drawing attached separately
I
15ina 11f14 T*5 official Inspection Form:Sub.uOare SOMP Di$NW SYMM•Page 15 0117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St.
Property Address
First Property Mgmt_
Owner Owner's Name
information is required for every Osterville MA 02855 11-13-12
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
ti
❑ Shallow wells
Estimated depth to high ground water. 12+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 9/22/83
Date
❑ Observed site(abutting property/obsefvation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Area and site high, No G.W. problem t.h. on design plan 9/22/83 no g.w. at 12'
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5 ins-11;10 Tine 5 ORdal inspection Forth:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
11 I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
749 Main St.
Property Address
First Property Mgmt.
Owner Owners Name
information is required for every Osterville MA 02855 11-13-12
page. Cityfrown State Zip Code Date of inspection
E. Report Completeness Checklist
® Inspection Summary: A, B,C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
l5fns•11r10 Title 5 Official lmpedon Forth:SubuuRace Savage Olsposal System•Page 17 or 17
Page 1 of 2
Town of Barnstable Geographic Information System
Parcel Viewer Custom Map Abutters Map Size ■ ■ Zoom Out 111'®1„In
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TOWN OF BARNSTABLE
LOCATION
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VILLAGE OS -f rvII ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �(/O
LEACHING FACILITY: (type) a" �f X��- �A) (size)
NO.OF BEDROOMS 1 lI (� L
BUILDER OR OWNER M A c,C D 1" r r Pro r� cW46-
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachi g facility) Feet
Furnished by �itS�eC,4ton �Ot�
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IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
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DATA
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Ordinance or Regulation
WARNING NOTICE
Name of Offender/Manager
Address of Offender MV/MB Reg. #
Village/State/Zip !� `
Business Name am/pm, on 20_
Business Address
Signature of Enforcing Officer
Village/State/Zip '
Location of Offense 1 a
p Enforcing Dept/Division
Offense
Facts
This will serve only as a warning. At this time no legal action has been taken.
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
Citizen Web Request Page I of 2
Citizen Request Management - Internal Use
Request ID: 22149 Created: 9/3/2008 1:56:28 PM
Status: Assigned To Staff - Assigned To: Cabot, Jaime
Health Office
Anonymous: No Category: General
E.C. Date: 9/17/2008
Created By: Flynn, Judith Citations:
Health Office
Time Worked: 1.00 Response Time: 6.50
x.r{ Requestor Details:
Email`
Request Location: Crazy Cakes
551 Main
Hyannis, Ma 02601
Parcel Number: Map: 000 Block: 000 Lot: 000
Request":
caller states that there is a strong odor (sewage) at the back of her building coming from
apartments located there. very unpleasant.
Request Work History:
Entered on 9/4/2008 4:32:12 PM
by Cabot, Jaime
Last modified on 9/4/2008 4:32:48 PM.
JAC observed standing water approximately 2" inches deep an area 20 x 20 feet in a parking
area adjacent to the Building at 559 Main St. Hyannis. Spoke to the occupants of unit #8 and
inspected the basement, observed dripping sanitary sewers in two locations s inside the building,
1/4" depth or less 2- 3 Diameter area standing water. Called Water Pollution control and received
message from Peter Doyle that WPCD has determined.that the leak is not in the Town Sewer.
Spoke to Adam Hostetter who stated that he will have a truck from Macombers pump out the
catch basin today 9/04/08.
Internal Note History:
y
http://issgl2/intemalwrs/WRequestPrint.aspx?ID=22149 9/4/2008
TOXIC AND HAZARDOUS MATERIA REGISTRATION FORM
NAME OF.BUSINESS: Robert A. Faiella, D.M.D. , M.M.Sc. Mail To:
BUSINESS LOCATION: 749 Main Street, Suite B, Osterville Board of Health
MAILING ADDRESS: Town of Barnstable
534
749 Main St, Suite B, Osterville, MA 02655 P.O. Box am
TELEPHONE NUMBER: (508)420-1124 Hyannis, MA 02601
CONTACT PERSON: Mary Beth
EMERGENCY CONTACT TELEPHONE NUMBER:
Does your firm store any of the toxic or hazardous materials listed below, either for sale or for
your own use, in quantities totalling, at any time, more than 50 gallons liquid volume or 25 pounds dry
weight? YES NO X
This form must be returned to the Board of Health regardless of a yes or no answer. Use the
enclosed envelope for your convenience.
If you answered YES above, please indicate if the materials are stored at a site other than your
mailing address:
ADDRESS:
TELEPHONE:
LIST OF TOXIC AND HAZARDOUS MATERIALS
The,Board of Health has determined that the following products exhibit toxic or hazardous character-
istics and must be registered regardless of volume. Please estimate the quantity beside the product that
you store:
Quantity/Case Quantity/Case
Antifreeze (for gasoline or coolant systems) Drain cleaners
Automatic transmission fluid Toilet cleaners
Engine and radiator flushes Cesspool cleaners
Hydraulic fluid (including brake fluid) CAL. Disinfectants
Motor oils/waste oils Road Salt (Halite)
Gasoline, Jet fuel Refrigerants _
Diesel fuel, kerosene, #2 heating oil Pesticides (insecticides, herbicides,
Other petroleum products: grease, lubricants rodenticides)
Degreasers for engines and metal .2&AL Photochemicals (fixers and developers)
Degreasers for driveways & garages Printing ink
Battery acid (electrolyte) Wood preservatives (creosote)
Rustproofers Swimming pool chlorine
Car wash detergents Lye or caustic soda
Car waxes and polishes Jewelry cleaners
Asphalt & roofing tar Leather dyes
Paints, varnishes, stains, dyes Fertilizers (if stored outdoors)
Paint & lacquer thinners PCB's
Paint & varnish removers, deglossers Other chlorinated hydrocarbons,
Paint brush cleaners (inc. carbon tetrachloride)
Floor & furniture strippers Any other products with "Poison" labels
Metal polishes (including chloroform, formaldehyde,
t 4AL Laundry soil & stain removers hydrochloric acid, other acids)
(including bleach) Other products not listed which you feel may
Spot removers & cleaning fluids be toxic or hazardous (please list):
(dry cleaners) H;—=V1C4L "s;-_ lac*4T"C;r—
1 6AL Other cleaning solvents
Bug and tar removers
GAL Household cleansers, oven cleaners
White Copy- Health Department/ Canary,Copy-Business
f TOWN OF BARNSTABLE
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WCATION ?Y'- 6201Ay S% SEWAGE # ?3 - EVE
VILLAG ASSESSOR'S MAP & LOT ILIZ!!IY 9-Z
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) dd 6r9
NO.OF BEDROOMS
BUILDER OR OWNER GoX,-9v S his/ A-11fIr
PERMITDATE: 9 �llu COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility /G�t Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by //
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X O CATION _ SEWAGE PERMIT NO.
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INSTA LLER'S NAME R ADDRESS
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B U I L D E R OR OWNER
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DATE PERMIT ISSUED e
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DATE COMPLIANCE ISSUED
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b THE CO EALTH OF MASSACHUSETTS
BOARD (QF HEALTH
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Aplirttiiun for Disposal Works Tonuirixriiuit Pprutii
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System a� _ ��i��� j,� ...(�...
� , _
� ocatio s � r �or Lot
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. / B d � .......................•••-••-•.... ..... ...
�................
Owner.......................................... .........�dss............ ..................
f g Iastaller d
dreas
Type o Size Lot.. ..�29Sq. feet t
U DWelll —No. of Bedrooms................... Expansion Attic ( ) Garbage Grinder ( )►..
Other-L-T'ype of Building ....OFF1......... No.-of persons...... , --------- Showers (0) — Cafeteria (AJ
p' Other fixtures .d . ...---•...........................................---........................_....._.................... . .... .._....._.
Design Flow...5�. .............�� � - letts�e�perso_�r day. Total daily flow........ ��..........................gallons.
WSeptic Tank—Liquid cap ity� ....gallons Length..........::.... Width................ Diameter................ Depth................
x Disposal Trench—No. ................... Width....:. .... Total Length............../...ITotal leaching area....... ..........sq. ft.
3 Seepage Pit No......... ..... D' eter...... ... Depth below inlet..... .. Total leaching area...V.O. ..sq. ft.
Z Other Distribution box ( Dosinz4ank ( 3
1.4 AA
Percolation Test Results Performed by... -l�4:r, f.... Date...;.x ?.:.�
-Z- ..........
Test Pit NO. 1.4 ..minutes per inch Depth of Test Pi ..__�.. -\..... Depth to ground water..O..\J-e.Y.1
44 Test Pit No. 2................minutes per inch Depth of Test Pit.... Depth to ground water....................
Description of Soi(....._. ....r. ....................................l..1 .............
.-.�.A.........
U ���Jj ......................
x .....
U Nature of Repairs or Alterations—Answer when applicable.................. .. -... ....
:............
.: .....:....................
..---...---•----------•---•-•--•-•.......-•------•-•----••-•...............•---••----••-•---.....-•-....•-•••-••--------------•----•••••--...--------..............................---•----.............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of THTN ; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee • sued by the board of health.
gned .....---•-----•--------------------•-----........-----••-•-•................. ...._ .. .._....
Date��jj
Application Approved ..---•....:�-- ..............•-------................................---....._ �C ZZ ?1...
Date
Application Disapprov f or t following reasons:..........................................................................................................---
.. ............. ......•---•••-.........._..........----------------•-•-----...._................----•--•------------....................................__... .Date ......----
PermitNo..................................................._.... Issued......................................................_
Date
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ti
THE COMMONWEALTH OF MASSACHUSETTS
` BOARD OF HEALTH
.... ..............OF.......!-'/ 4 .. e-_r.........................................
Appliratiun for Disposal Works Tonstrurtiun rrrmit
Application is hereby made for a Permit to Construct k ) or Repair ( ) an Individual Sewage Disposal
System at
........:: . � ......................._..............._ .... .........._....
... o. d s...................................te
Owner Add ss
------- -•--••--•.................._•-----.................. _....-----...----.....----•--•.....-_.... .........------•--••---•--................---•...
Installer ddress
�q Type of Building Size Lot.. ..12�Sq. feet �-
�..� Dwelling—No. of Bedrooms....................... ...................Expansion Attic ( ) Garbage Grinder ( )
aOther_Lq_ype
of Building No. of persons......� /-1------•-•- Showers (v) — Cafeteria KJ►O
dOther fixtures� ......................................................•-••-•..................•-•-- --••--. ---•---------•--......_...
DesignFlow.L_ _ �_ er day. Total daily .flow.......... ........ gallons.
Gd Septic Tank—Liquid cap cit;/ ..•.�galllons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No.................. . g ..-� j:...i� leaching q.
x _. Width................... Total Length . '�'otal leachi area_._.............._..s ft.
3 Seepage Pit No.........E ...... Dia�meter......� .._ Depth below inlet....-c,�,?--.-��.-.. Total leaching area...�Z-l)..sq. ft.
z Other Distribution box ( '- Dosing tank ( ) k - --
''' Percolation Test Results Performed by.._. - t _.�.. ft�-. _: ..___. ��.._. Date_. .'. ,�.:: .�......
�j = -
,`'la Test Pit No. 1 ...minutes per inch Depth of Test PW.•(_�----•--- Depth to ground
Li. Test Pit No. 2............:...minutes per inch Depth of Test Pit....i__ ..... Depth to ground water.......
....._.....__`
a € ........ --•---• .... I.....
........... .............. ---.... .
O Description of Soil I..... _ `.� ...... t 1 t. ��U f - :Q--...i��_..`.E..,�.t....-� .'�`t �1-` �UL
dj
... .
......................... :.r _..1... ...t�.......C�. ....... (( T
...
U Nature of Repairs or Alterations—Answer when applicable.............. ... ...........:...........
----•..........................•-••--.............-•-•-•--•••-•••-•---•--...•-----•...•-•-------.......................-•-••--•-•-•----...•---•••-••-......-•--•••......._....-•-•-•.....--••--•--......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b ssued by the board of health.
gned .......-•---•---•------------------------------------------•--•-•-----•--•- ..................... ._....
Date -^s
Application Approved;$y._..' ---...........- -...; F ....:! '.Z.
Date
Application Disapprov for t following reasons:..........................................................................................................---
................................ .........................-_.....•-----.........._....•••--•---....__......_.......................••--•-...........................•..•---.. . . .........
Date
PermitNo......................................................._ Issued.....................................................--
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
fErrttfiratt of faumpliana
wo THIS T ER FY, That the Individual Sewage Disposal System constructed _,. Repaired ( )
byr�:...._.:.. ':... ... ..... .... %`.= ................................� _
�,`.. '� J. .... ' Installer -•- � ......
at-............................ ! ----- l .._..... . � :.� --•• ---•-•......•-------
c'lG. �- -,- f...
has been installed in accordan �.__
c with the provisions of T � j ! #, State Sanitary Co as abed in the
application for Disposal Works Construction Permit No. __..'::.l ._._ ......... dated_../_..L:L...............................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILV FUJICTION SATISFACTORY.
DATE..L! _ .lr� �r ........ .................... Inspector..... ........_....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
(j J � .....O F....................................... ............................... 7
No.LL ............. F> ........- .............
- a,
3�isu r _ Turtutrnrtiun frrmft
Permission is by granted........;-,,... ................................___
to Construct for Re •r ( ) divi r-w Disposal System
atNo.........................._ 7.."......... � '�. ---......�
r 6 rrc.. ..---•-- --...--•--•..... .. . ..............................•---... ... -. ... .-:
Street .--
as shown on the application for Disposal Works Construction Permit No... .: '....�,...Dated ' �;Z.:............
- -•...... ... .............•---••-----••-•..................---:......................_
Board of Health
A
DATE .......................................
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